Conservative

• analgesia in an adult:
  • severe pain:
    • an opioid e.g. pethidine i.m. (but see ** below)
    • anti-emetic e.g. metoclopramide 10 mg i.m.
    • NSAID e.g. diclofenac sodium 150 mg p.o. or p.r. daily in divided doses
  • less severe pain:
    • diclofenac 150 mg p.o. or p.r. daily in divided doses
      
      
• fluid replacement commensurate with patient's needs - an unduly high fluid intake may reduce the rate of ureteric peristalsis, reduce stone clearance and by increasing back pressure effects on the nephrons, cause renal damage
  
  
• collect and sieve the urine to see if a stone was passed

NICE suggest that (1):

• pain management
  • a non-steroidal anti-inflammatory drug (NSAID) should be offered by any route as first-line treatment for adults, children and young people with suspected renal colic.
  • intravenous paracetamol should be offered to adults, children and young people with suspected renal colic if NSAIDs are contraindicated or are not giving sufficient pain relief
  • opioids should be considered for adults, children and young people with suspected renal colic if both NSAIDs and intravenous paracetamol are contraindicated or are not giving sufficient pain relief
• do not offer antispasmodics to adults, children and young people with suspected renal colic
• medical expulsive therapy
  • alpha blockers should be considered for adults, children and young people with distal ureteric stones less than 10 mm
• stenting before shockwave lithotripsy
  • do not offer pre-treatment stenting to adults having shockwave lithotripsy (SWL) for ureteric or renal stones
  • consider pre-treatment stenting for children and young people having SWL for renal staghorn stones
    
    
• consider watchful waiting for asymptomatic renal stones in adults, children and young people if:
  • the stone is less than 5mm or
  • the stone is larger than 5 mm and the person (or their family or carers, as appropriate) agrees to watchful waiting after an informed discussion of the possible risks and benefits.

Conservative treatment should be abandoned if sepsis proximal to an obstructing stone is suspected: fever in a patient with uncomplicated renal colic is uncommon and should be taken seriously - referral criteria from primary care are included in the linked item.

Notes:

• ** a systematic review concerning the use of nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for renal colic concluded that:
  • NSAIDs and opioids can provide effective analgesia in acute renal colic (2)
  • opioids are associated with a higher incidence of adverse events, particularly vomiting. Given the high rate of vomiting associated with the use of opioids, particularly pethidine, and the greater likelihood of requiring further analgesia, we recommend that if an opioid is to be used it should not be pethidine (2)
    
    
• primary care or secondary care management of acute renal colic (3):
  • about 90% of stones that cause renal colic pass spontaneously
  • patients with acute renal colic should be treated with fluids and analgesics (and should strain the urine to recover stone for analysis)
  • often renal colic is a prompt for immediate hospital admission
    • however a review suggested that this condition may be initially managed in primary care and immediate hospital admission is indicated if:
      • highgrade obstruction or failure of oral analgesics to relieve pain may require hospitalization, or,
      • a urinary tract infection in the setting of an obstruction - this is a urologic emergency requiring immediate drainage, usually with a ureteral stent
        
        
• medical therapy to facilitate passage of ureteral calculi
  • small, less than 5-mm distal ureteral stones, will most likely spontaneously pass within 4 weeks, without the need for urologic intervention
  • study evidence (4) suggests that "medical expulsive therapy," using either alpha-antagonists or calcium channel blockers, augments the stone expulsion rate compared to standard therapy for moderately sized distal ureteral stones

Reference:

• NICE (December 2018).Renal and ureteric stones: assessment and management (NG118)
• Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev 2004;(1):CD004137
• Wasserstein AG. Nephrolithiasis: acute management and prevention. Dis Mon. 1998 May;44(5):196-213
• Singh A et al. A systematic review of medical therapy to facilitate passage of ureteral calculi. Ann Emerg Med. 2007;50:552-63.